Insurer: __________________________________________ Insurer: _____________________________________________

Employee Instructions: Please print using black or blue ink. Please fill out the entire application for each person for whom coverage is being sought.

Employee’s First Name, Middle Initial and Last Name: ___________________________________________________________

Social Security No.: __________________ Birth Date: _________________ Sex: _______ Height and Weight:_____________

Street or Post Office Address: ______________________________________________________________________________

City: _______________________________ County:____________________ State: ___________________Zip: ____________

Home Phone: __________________Work Phone: _________________ Email: _____________________ [ ] Home [ ] Work

1. For your current employer: What was your first day of employment? ____/____/____

How many hours, on average, do you work each week? ______

a) [ ] Single [ ] Married [ ] Legally Separated [ ] Divorced [ ] Widow or Widower

If you are married, legally separated, divorced or widowed, please indicate the date that the event occurred: __________

If you are married, please indicate the county and state, or country in which you were married: _____________________

If you are married, please indicate your former or maiden name: __________________________________

c) On COBRA or State Continuation? [ ] Yes [ ] No

If “Yes,” provide start date and reason: _________________________________________________________________

Please select the type of health insurance coverage for which you are applying:

[ ] Employee Only [ ] Employee and Spouse [ ] Employee and Dependent Child(ren) [ ] Employee, Spouse and Dependent Child(ren)

a) List all dependents, spouse and child(ren) applying for insurance. If you need additional space, please use a separate sheet of paper and attach it to this application (please sign and date the additional sheet).

b) Does the dependent child(ren) named within this application live with you at the address shown above? [ ] Yes [ ] No

If “No,” please list the dependent child(ren)’s name and address(es):

______________________________________________________________________________________________________